Provider First Line Business Practice Location Address:
4440 HIGHWAY 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLUMMER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83851-9681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-859-3168
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2023